ERM-14 and Instructions
Broker/Agent of Record Sample
NCCI Mod Authorization Form
Online Officer Exemption
Employer's First Report of Injury
Alabama State Specific Forms
Drugfree Workplace
Department of Labor – Workers' Comp - labor.alabama.gov
Independent Agents of AL - www.aiia.org
First Report of Injury or Illness
Arkansas State Specific Forms
HS-36-A Drugfree Workplace
AR Workers’ Comp Commission - www.awcc.state.ar.us
Independent Agents of AR - www.iiaar.org
Employers First Report of Occupational Injury or Illness
CT C-30 form Notice of Claim for Compensation
DMV Credential Verification - www.dmvselfservice.ct.gov
Connecticut Employee Safety - portal.ct.gov
Department of Labor - www.ctdol.state.ct.us
Independent Insurance Agents and Brokers of DC
DC - Department of Employment Services - Workers' Comp and Forms
DFS-F2-DWC-1 First Report of Injury or Illness
09-1 Drug Free Application
09-3 Safety Credit Form
09-4 FCCPAP Form (Florida Contracting Classification Premium Adjustment Program)
Florida Association of Insurance Agents (FAIA) - www.faia.com
Latin American Association of Insurance Agencies - www.laaia.com
Home Page for the Florida Division of Workers' Compensation Website - www.myfloridacfo.com
Division of Workers' Compensation Databases - dwcdataportal.fldfs.com
This link has a number of useful state databases, such as Proof of Coverage and WC Policy Search
W-1 First Report of Injury or Occupational Disease
Drug Free Credit – Online only
WC-10 Election or Rejection of Coverage
Drug Free Application
Independent Insurance Agents of GA - www.iiag.org
State Board of Workers' Compensation - sbwc.georgia.gov
First Report of Injury or Illness
Louisiana State Specific Forms
LA Workers’ Comp Commission - www.laworks.net
Independent Agent of LA - www.iiabl.com
First Report of Injury or Illness
Mississippi State Specific Forms
MS Workers' Comp Commission - mwcc.ms.gov
Independent Agent of MS - www.msagent.org
Report of Injury
North Missouri Specific Forms
Loss Cost Filings
MO Dept of Insurance - insurance.mo.gov
Trusted Choice Independent Agents - www.trustedchoice.com
MO Association of Insurance Agents - www.moagent.org
First Report of Injury or Illness
North Jersey State Specific Forms
NJ Compensation Rating & Inspection Bureau/NJCRIB - www.njcrib.com
NJ coverage search - www.njcrib.com
NJ Independent Agents - www.biginj.org
Employer's Report of Employee's Injury or Occupational Disease to the Industrial Commission
North Carolina State Specific Forms
NC Industrial Commission - www.ic.nc.gov
NC Rating Bureau - www.ncrb.org
NC Coverage Database - ccms.ic.nc.gov
Independent Agent of NC - www.iianc.com
First Notice of Claim For Compensation
Oklahoma State Specific Forms
OK Workers’ Comp Commission - www.ok.gov
Independent Agent of OK - www.iiaok.com
LIBC-90 First Report of Injury
LIBC-500 Remember: It is Important to tell Your Employer About your Injury
Experience Modifications - www.dcrb.com
Coverage verification and Bureau code search - www.dli.pa.gov
Independent Agents of PA, MD, and DE - www.iabforme.com
Employer's First Report of Injury or Illness
Tennessee State Specific Forms
TN Department of Insurance - www.tn.gov
Professional Insurance Agents of TN - piatn.com
First Report of Work Injury or Illness
Texas State Specific Forms
TX Dept of Insurance - www.tdi.texas.gov
Agent appointments - www.tdi.texas.gov
Coverage verification through TX Comp - www.tdi.texas.gov
Independent Agents of TX - www.iiat.org
First Report of Injury
16A Rejection of Coverage
Address Change
Professional Insurance Agents Association - Virginia and DC - www.piavadc.com
VA Workers' Compensation Commission - vwc.state.va.us
Normandy Insurance Services
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